CurrentAnthemPolicy N/A

Use of a Non-Participating Provider Advance Patient Notice Policy

Governs required advance written notice (APN Form) that participating providers must give Anthem members when referring or arranging care with non-participating providers or facilities, excluding emergencies and prior-approved out-of-network referrals.

Policy Summary

PayerAnthem

PolicyUse of a Non-Participating Provider Advance Patient Notice Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2021

Next Review DateN/A

Key ActionParticipating providers must present and obtain a signed Advance Patient Notice (APN Form) from the member at least 7 days before scheduling services or making a referral to a non-participating provider or facility and furnish copies to Anthem within 15 days of request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 daysminimum advance notice required before scheduling services or referrals

15 daystimeframe providers must furnish signed APN Forms upon Anthem request

Administrative actionspossible consequences for documented pattern of improper referrals (denial/recoupment/termination)

Exclusionspolicy does not apply to emergency situations or when Anthem prior approval obtained

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

When APN Form Is Required

APN Form requirements and consequences

Covered when ALL of the following are met:

ALL of the following

ALL of the following
- APN Form must be presented a minimum of 7 days prior to scheduling services or making the referral>= 7 days
- Signed and dated APN Form must be documented and retained in the member's records and provider files
If Anthem requests copies of signed APN Forms, furnish copies within 15 days
Respond to Anthem requests for documentation

Exceptions (APN Form NOT required)

Emergency situations
When Anthem prior approval for out-of-network care has been obtained (APN Form not required)
When prior written authorization permits use of a non-participating assistant surgeon on an in-network basis

ALL of the following

Member choices
- Member may decline out-of-network care and request arrangement with an in-network provider
- Member may voluntarily accept out-of-network care and acknowledge potential additional costs as specified in their benefit contract
APN Form must include explanation that absent special circumstances the non-participating provider is prohibited from waiving member cost sharing amounts

ALL of the following

Anthem may monitor compliance and, for providers with a documented pattern of improper referrals, take administrative actions including denial and recoupment of related claims and/or termination from Anthem networks
If a claim is administratively denied under this policy, the provider is prohibited from balance billing the member

ALL of the following

Scheduling an endoscopy that will involve a non-participating anesthesiologist — present APN Form at least 7 days in advance unless prior approval obtained
Collecting a lab specimen in-office and sending it to a non-participating reference lab — present APN Form before specimen is sent unless prior approval obtained
Scheduling a procedure at a non-participating surgical suite — present APN Form at least 7 days before the procedure unless prior approval obtained

Provider Responsibilities and Enforcement

Documentation Required

Advance Notice & Documentation Requirement

To be compliant with this policy, a participating provider must provide the member with Anthem's Advance Patient Notice (APN) Form for signature at least 7 days before scheduling services with or making a referral to any non‑participating provider or facility. The signed and dated APN Form must be retained in the member's medical record and the provider's files. The APN Form is not required for Emergency situations or when the provider or member has obtained Anthem's prior approval for an out‑of‑network referral. If Anthem grants prior approval to obtain services from/at an out‑of‑network provider or facility on an in‑network basis, the APN Form is not required.

APN Form must be provided >= 7 days prior to scheduling or referral
Signed APN Form must be kept in member record and provider files
Not required for Emergencies or when Anthem prior approval obtained

Note

Advance Notice Monitoring

Anthem may periodically request copies of signed APN Forms to monitor compliance. Participating referring providers must furnish copies of signed APN Forms to Anthem within fifteen (15) days of request. Providers should maintain documentation demonstrating timely delivery of the APN Form and the member's signed acknowledgment.

Provide copies of signed APN Forms within 15 days when requested
Maintain documentation of APN delivery and member signature

Prior Authorization

Exclusions / Prior Approval

Providers may avoid the APN requirement only if they or the member obtain Anthem's prior approval for the out‑of‑network referral. Contact Provider Services at (800) 922-3242 to request prior approval. When prior approval is granted by Anthem to obtain services from/at an out‑of‑network provider or facility on an in‑network basis, retain documentation of that approval in the member's record in lieu of the APN Form.

Prior approval from Anthem exempts the APN Form requirement
Document and retain Anthem's prior approval in member record
Provider Services: (800) 922-3242

Denial Risk

Enforcement and Consequences

Anthem enforces this policy and may take corrective action for noncompliance. Providers and facilities that establish a documented pattern of improperly referring members to non‑participating providers may be subject to: (1) administrative denial and recoupment of the referring participating provider's claims that correspond to the non‑participating provider services, and/or (2) termination from Anthem's network(s). When claims are administratively denied under this policy, the participating provider is prohibited from balance billing the member for those services.

Possible corrective actions: administrative claim denials and recoupment
Possible corrective actions: termination from Anthem networks
Providers are prohibited from balance billing members if claims are administratively denied

Key Definitions

inv-07: APN Form

DefinitionAdvance Patient Notice (APN Form) — written form created by Anthem to notify members of referrals to or involvement with non-participating providers or facilities and to document member acknowledgment.

Required timingAPN Form must be provided to the patient for signature at least 7 days before scheduling the service or making the referral.

Member options on formMember may decline out-of-network care and request in‑network arrangement, or voluntarily agree to receive out-of-network services and acknowledge potential additional costs (see signature/waiver statements).

Retention and accessProviders must document/retain the signed APN Form in member records and furnish copies to Anthem upon request (per policy documentation requirements).

inv-08: Non-participating provider/facility

DefinitionNon-participating provider/facility — any physician, provider or facility that does not participate in Anthem's network, including examples such as in-office anesthesiologists, surgical assistants, specialty drug vendors, in‑office home infusion therapy, DME vendors, reference labs, ambulatory surgical centers, endoscopy suites, and surgical suites.

Member rightsMembers have the right to receive services from participating/in-network providers to obtain full benefits under their coverage; APN informs them of in‑network options and Member Service contact information.

Form contentAPN Form includes referring physician and non‑participating provider/facility details, date of service, patient choices (decline or accept out‑of‑network care), and signature block for patient or legal guardian.

OpenPayer

Use of a Non-Participating Provider Advance Patient Notice Policy

When APN Form Is Required

Coding and Timing

Provider Responsibilities and Enforcement

Key Definitions